1. Chapter 2: Assessments Types & Scheduling June 2, 2015 1-3PM

2. Objectives Understand Assessment types and definitions
Understand the difference between scheduled and unscheduled assessments
Understand how to schedule assessments
Understand when assessments can be combined and when they cannot be combined

3. Observation (Look Back) Period
Look Back Period & ARD
Observation (Look Back) Period
Time period over which resident’s status captured
Item-specific
Assessment Reference Date (ARD)
Last day of observation (look back) period-11:59 PM
Must set ARD on MDS Item Set or software within required timeframe of assessment being completed
OBRA & Scheduled PPS Assessment scheduling ARD to ARD

4. Entry
Person enters or re-enters facility
Admission
Reentry

5. Leave of Absence Temporary home visit of at least one night
Therapeutic leave of at least one night
Hospital observation stay less than 24 hours and the hospital does not admit the patient.

6. Discharge Return Not Anticipated Discharge Return Anticipated
Discharges
Discharge Return Not Anticipated
Discharge Return Anticipated
DRNA
Discharged & not expected to return within 30 days
DRA
Discharged & expected to return within 30 days
Out of here ---
Not coming back!

7. Entry and Discharge Reporting Assessments & Tracking Records A0310F, G

9. Tracking Records Discharge Assessments
Complete regardless of payment source or length of stay in Nursing Home or Swing bed
Tracking Records
Entry
Admission
Reentry
Do not complete when return from LOA
Death in the Facility
Do complete even if occurs when on LOA
Discharge Assessments
Return not Anticipated Assessment (DRNA)
Return Anticipated Assessment (DRA)
Do not complete when goes on LOA

10. Entry Tracking Record (A310F=01) Completion: Entry Date + 7 days Cannot combine with any assessment
Admission (A1700=1)
Reentry (A1700=2)
1. Admitted for first time
2. Readmitted after DRNA
3. Returned after DRA but
(a) OBRA Admission Assessment not completed before discharge or
(b) Did not return within 30 days
Returned after DRA and
OBRA Admission
Assessment
completed before
discharge
and
Returned within 30
days

11. Entry Tracking Record Admission or Reentry??
Mr. S. was admitted to NH on 2/5/XX following a CVA. He regained most of his function & returned home. He was DRNA.
Eight months later he underwent surgery for a total knee replacement. He returned to NH for rehab on 10/7/XX.
Mr. W. was admitted to NH on 10/1/XX. Three weeks later he become SOB during lunch and developed labored breathing.
He was DRA to hospital on 10/22/XX. On 10/25/XX he returned to NH.

12. Death in Facility Tracking (A0310F=12)
Dies
in facility
on leave of absence
in ambulance
MDS completion
Discharge (death) date + 7 days
Transmit
Discharge (death) date + 14 days
Can not combine with any assessment

13. Discharge Assessments
Discharge Return Not Anticipated
Discharge Return Anticipated
DRNA
A0310F=10
Discharged & not expected to return within 30 days
DRA
A0310F=11
Discharged & expected to return within 30 days
ARD: Discharge Date
MDS Completion: Discharge date (ARD) + 14
Days
Transmit: Completion date + 14 Days
Can combine with other assessments if ARD meets requirements of other assessment also.

14. Discharge (A0310G) 1. Planned or 2. Unplanned
Unplanned discharge
acute-care transfer to hospital or ED to stabilize condition or determine need for acute-care admission
unexpectedly leaving facility against medical advice
unexpectedly deciding to go home or to another setting
Use dash, “-”, when unable to determine response
Kansas Specific - DRA & does not return, do not need to modify assessment

15. OBRA-OMNIBUS RECONCILIATION ACT
Assessments: A0310
PPS – PROSPECTIVE PAYMENT SYSTEM
OMRA – OTHER MEDICARE REQUIRED
ASSESSMENTS

16. Assessments OBRA – A0310A

17. OBRA Assessments (A0310A) Types 01. Admission 02. Quarterly 03. Annual
04. Significant Change in Status
Discharge
05. Significant Correction in Prior Comprehensive Assessment
06. Significant Correction in Prior Quarterly
Assessment
Assessment Summary Table (Pages 2-15 and 2-16)

18. Comprehensive Assessments Admission (A0310A=01)
Resident:
1. First time in facility
2. Readmitted after DRNA
3. Returned after DRA but
(a) discharged before completion of OBRA admission assessment OR
(b) did not return within 30 days
of discharge

19. Comprehensive Assessments Admission Cont.
ARD - No later than 14th day of admission
MDS/CAAs completion - No later than 14th day of admission
(Entry Date +13 calendar days)
Care plan completion
CAAs completion + 7 days
Transmission
Care plan completion + 14 days

20. Admission Assessment – Scenario
Mr. H. entered the facility on Jan. 3rd (Day 1).
To allow combining the Admission Assessment and a 5 Day Medicare Assessment, the ARD was set for the Jan. 8th (Day 6).
The MDS completion date was Jan. 11th (Day 9).
CAA completion date was Jan. 13th (Day 11).
Care Plan completion was Jan. 19th (Day 17).
The MDS was transmitted on the Jan. 25 (Day 23).
Remember you can always move up the dates for the OBRA assessments. Earlier is OK. Late is not.

21. Comprehensive Assessments Annual (A0310=03)
ARD - No later than:
ARD of previous comprehensive assessment days and
ARD of previous quarterly assessment days
MDS/CAAs completion - ARD + 14 days
Care plan completion
CAAs completion + 7 days
Transmission
Care plan completion + 14 days

22. Comprehensive Assessments Significant Change in Status Assessment (SCSA) (A0310=04)
Decline or Improvement in resident’s status that:
1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical
interventions ;
2. Impacts more than one area of resident’s health status ; and
3. Requires IDT review &/or revision of care plan.

23. Comprehensive Assessments SCSA cont.
Hospice Services
Started or revoked
Notify KDADS PASRR (Sue Schuster – ) when SCSA done on resident:
Previously identified by PASRR to have MI, Intellectual Disability (ID) or related condition
New diagnosis of MI, ID, or related condition or new behaviors with symptoms of MI
Exception: if have primary DX of dementia

24. PASSR Information
PASSR Information –Every resident is screened for MR/DD or MI upon admission. Only those that have a diagnosis of MR/DD or MI will need to have a Level II review.
CMS does require that the facility report to KDADS when a significant change occurs for residents that have a Level II PASRR determination in case a new resident review is needed
KDADS Memo for Reporting : Definition of Significant Change:
A change in cognitive abilities and/or social adaptive functioning as determined by a psychological assessment that documents either a significant gain or loss in cognitive abilities and/or social adaptive functioning.
A change in physical health which results in a major decline or improvement in the functional status of the resident which is unexplained by the use of medication, an acute illness, infection, or injury. KDADS Guidance
For people with mental illness the following are specific circumstances or situations that are considered a “significant change in condition” or people with mental illness:
A newly diagnosed or newly discovered diagnosis of Major Mental Illness for a resident without a PASRR Level II.
An increase in need for supportive services due to a Major Mental Illness that was not present at admission to the NF.
Inpatient treatment due to a Major Mental Illness that was not present at admission to the NF.
DO NOT make a referral if:
A Categorical Determination has already been made that the individual does not need further evaluation due to dementia, terminal illness, certain medical conditions, etc.
The individual in the nursing facility already has a Level II without a time limitation.
Resident was approved for a time-limited stay and can’t be discharged by the approved end date.
B. For people with mental retardation/developmental disability (MR/DD) the following are specific circumstances and
situations that must be considered a “significant change in condition” for people with MR/DD: A newly diagnosed or
newly discovered diagnosis of MR/DD for a resident without a PASRR Level II.
Resident was approved for a time-limited stay and cannot be discharged by the approved end date.
Resident was approved for NF placement for stabilization/rehabilitation of a medical condition which has resolved and
nursing facility care is no longer needed.
Resident has a change in cognitive abilities or functioning as determined by a psychological assessment that documents a significant gain or loss not due to a medical condition.

25. Comprehensive Assessments SCSA cont.
ARD - No later than 14th day after determination of significant change, hospice starts or is discontinued
Resets clock for annual assessment
MDS/CAAs completion
No later than 14th day after determination
Care plan completion
CAAs completion + 7 days
Transmission
Care plan completion + 14 days

26. Scenario – Significant Change
Mr. Blue had experienced a bout with the flu and seemed to be improving. He continued to pick at his food and needed more assistance with dressing and walking. On Wednesday the 4th day of the month, the bath aide found he lost 10 pounds in the last month. The nurse calculated it to be a 5% weight loss in 30 days.
The physician and dietitian were notified. The IDT decided to see if Mr. Blue would improve over the weekend.
On Monday the 9th, he had not lost any more weight but was still needing more assistance with dressing and walking, and had a stage 2 PU on his coccyx.
Due to his initial weight loss, decrease in ADLs, and now a Stage 2 PU the IDT realized a significant change assessment was needed to guide the revision of the care plan.
Although they could wait until the 23rd for the ARD and complete the MDS & CAAs on the 24th (Day 15 after the decision was made a significant change was needed.) It was more feasible to set the ARD for the 18th, MDS completion the 20th & CAA completion on the 23rd and Care Plan completion the 30th.

27. Non-Comprehensive Assessments Quarterly (A0310=02)
ARD
No later than ARD previous OBRA assessment + 92 days
MDS completion
ARD + 14 days
Transmission
MDS completion + 14 days

28. OBRA Assessments Admission Quarterly Not >92 Days Not >92 Days
Annual
Not >92 days
Total = Not > 366 Days
Entry Tracking

29. OBRA Assessments Admis-sion Quart-erly Signif- icant Change
Not >92 Days
Annu-al
Not >92 days
Total = Not > 366 Days
Entry Tracking

30. Correction of OBRA Assessments
Significant Error
Overall condition not accurately represented on assessment - Incorrect coding of MDS
Significant Correction to Prior Comprehensive Assessment (SCPA), (A0310=05)
Significant Correction to Prior Quarterly Assessment (SCQA), (A0310=06)
Chapter 5 – Submission & Correction of MDS Assessments

31. Assessments -PPS Medicare (A0310B, C)
Skilled Therapy
5 days a week
Skilled Nursing
7 days a week

32. PPS Assessments A0310B Nursing Home/ Swing Beds
Scheduled assessments Medicare Part A Stay
01. 5 day
day
day
day
day

33. PPS Scheduled Assessments Medicare Part A Stay
5 Day
14 Day
30 Day
60 Day
90 Day
Entry Tracking

34. MEDICARE PPS ASSESSMENTS
Scheduled Assessments
Predetermined time period for setting ARD
Grace Days
Assessment delayed
Unscheduled
Other Medicare Required Assessment (OMRA)
Outside of standard Medicare scheduled assessments
Assessment Summary Table (Pages 2-43, 44, & 45)

35. PPS Scheduled Assessments
Type
MDS A0310B
Code
ARD
Grace Days
Standard Medicare
Payment Days
5-day 01
1 – 5
6 – 8
1 – 14
14-day 02
13 – 14
15 – 18
15 – 30
30-day 03
27 – 29
30 – 33
31 – 60
60-day 04
57 – 59
60 – 63
61 – 90
90-day 05
87 – 89
90 – 93

36. PPS Scheduled Assessments
5 Day
14 Day 14
Day
30 Day
60 Day 90
To Hospital
5 Day
Entry Tracking
Discharge
Assessment
Entry Tracking

37. PPS Unscheduled Assessments Changes and Corrections A0310B=07, A0310D
Significant Change Status Assessment (SCSA) (OBRA)
Swing Bed Clinical Change Assessment
A0310D
Significant Correction to Prior Assessment (SCPA) (OBRA)

38. SCSA – Payment Resident on Medicare Part A
SCSA Only - RUG-IV classification & associated payment rate(AP) begins on ARD
SCSA combined with scheduled PPS assessment & ARD not set on Grace Day
RUG-IV classification & AP begins on ARD
SCSA combined with scheduled Medicare-required assessment & ARD set on Grace Day
RUG-IV classification & AP begins on first day of payment period of scheduled PPS assessment standard payment period.

39. PPS Unscheduled Assessments Therapy A0310B=07, A0310C
All facilities are 7 day per week facilities
Day of therapy = any day received at least 15 minutes of therapy
A310. C. Other Medicare Required Assessment (OMRA)
1. Start of Therapy (SOT)
Optional
2. End of Therapy (EOT)
Required
O0450. End of Therapy Resumption (EOT-R)
4. Change of Therapy (COT)

40. Start of Therapy (SOT OMRA) A0310C=1
Completion Optional
Classify into RUG-IV Rehab plus Extensive or Rehab group
ARD - set Day 5, 6,or 7 after start of earliest therapy – SLP, OT, PT
Day 1 = Day of Evaluation
If SOT done as stand alone assessment or combined with Discharge Assessment must set ARD for a date within ARD window but ARD date must be set no more than two days after the window has passed
Payment - Effective the first day of therapy

41. Start of Therapy OMRA - SOT
Sun
Mon
Tues
Wed
Thurs
Fri
Sat 1 2 3 4 5
5 Day 6 7 8 9 10 11 12 13 14
14 Day 15
16 OT/PT Eval
Day 1 17
OT/PT
Day 2 18
Day 3 19
Day 4
20 X
Day 5
21X
Day 6
22 X
Day 7 23 24
Mr. A. had a ORIF of his hip. Due to an infection, he was not able to start therapy. Since he was receiving skilled nursing services, 5 day & 14 day PPS assessments were completed. On Day 16, he was evaluated & determined to be able to start therapy. ARD for SOT had to be set on Day 5, 6, or 7 after day of evaluation day.

42. End of Therapy (EOT OMRA) A0310C=2
Completion Required if Resident in:
RUG IV Rehab Plus Extensive or Rehab Therapy Group
1. All Therapy ends completely and
Resident continues on Part A for Skilled
Nursing
Example:
Mr. Jones was receiving OT and PT and Skilled Nursing Services (Part A). He was discharged from OT and PT on Friday and continued on Skilled Nursing Part A.

43. End of Therapy (EOT OMRA) A0310C=2
Completion Required if Resident in:
RUG IV Rehab Plus Extensive or Rehab Therapy Group
2. No therapy provided for at least 3
consecutive days, regardless of reason
Resident may or may not be on Part A for Skilled Nursing

44. EOT OMRA – Example 2
Mrs. Brown received OT and PT on Friday. She was not scheduled for therapy Saturday or Sunday and refused therapy on Monday.
Mrs. Brown was not receiving Skilled
Nursing Services (Part A).
Mrs. Green received OT and PT on Friday She was not scheduled for therapy Saturday or Sunday and refused therapy on Monday. Mrs. Green was still receiving Skilled Nursing Services (Part A).

45. EOT OMRA Info cont.
ARD - must be set on Day 1, 2, or 3 after all therapy discontinued or not provided for 3 consecutive days – planned or unplanned
Day 1 is first day after last day therapy received
Day 1 is date new non-therapy RUG established
Not required if resident discharged:
on or prior to 3rd consecutive day of missed therapy

46. End of Therapy OMRA - EOT
Sun
Mon
Tues
Wed
Thurs
Fri
Sat 1
OT/PT 2 3 OT PT 4 5 6
7 No Therapy Day 1 X
8 No Therapy Day 2
9 No Therapy Day 3 10 11 12 13 14 15 16 17 18 19 20 21
Mr. Jones was receiving OT and PT and Skilled Nursing Services
(Part A). He was discharged from OT and PT on Friday and
continued on Skilled Nursing Part A.
Day 1 is Saturday. EOT ARD had to be set for Sat., Sun., or Mon.

47. EOT OMRA Completed D/T 3 Consecutive Missed Days & Therapy Resumed
Completion Option
1. Wait until next scheduled PPS assessment
Will remain in RUG IV Non-Rehab group
2. SOT OMRA
Therapy not provided more than 5
consecutive days since last day of therapy OR
Therapy will not resume at same RUG IV
Rehab group as prior to EOT OMRA
New therapy evaluation required

48. EOT OMRA Completed D/T 3 Consecutive Missed Days & Therapy resumed EOT-R
Option
3. EOT OMRA with Resumption (EOT-R)
If therapy resumes 5 days or less after last day of therapy AND
therapy will resume at same RUGS IV Rehab
group AND same therapy plan of care as prior to EOT OMRA
EOT-R Transmission
If EOT OMRA not transmitted before EOT–R determined
Code EOT-R (O0450A & B) on assessment & transmit
If EOT OMRA transmitted before EOT–R determined
Modify Assessment. Do not change ARD. Complete EOT- R Item O0450. A & B., Check X0900E & transmit.

49. End of Therapy OMRA with Resumption - EOT-R
Sun
Mon
Tues
Wed
Thurs
Fri
Sat 1
OT/PT 2 3 4 5 OT PT 6
OTPT
7 No Therapy Day 1
8 No Therapy Day 2
9 No Therapy Day 3
10 No Therapy
Day 4
11 EOT-R
Therapy must resume by this day at same RUG
Day 5 12 13 14 15 16 17 18 19 20 21

50. Change of Therapy (COT) OMRA A0310C=4
Completion required when
Resident receiving any amount of skilled therapy
Therapy or to extent current RUG no
longer accurate to reflect RUGs
classification or payment.
Change or
Reimbursable therapy minutes (RTM)
Days of therapy
Number of disciplines

51. Change of Therapy
Observation Period: 7 successive days with 7th day being ARD if COT required
Observation Period Situations
1. Day 1 of Observation Period starts the first day after the ARD of most recent Scheduled or Unscheduled PPS assessment
Ex. 30 day PPS assessment. Observation Period is Day 31 through Day 37. If COT required, ARD must be set for Day 37. Day 38 is first day of next Observation Period.
2. If last assessment was EOT with EOT-R,
Day 1 of Observation Period is the day therapy
resumed (O0450B)
Ex. Therapy resumed Day 40, Observation Period is Day If COT required, ARD must be set for Day 47.

52. COT continued
The COT OMRA may be completed when a resident is not currently classified into a RUG-IV therapy group, but only if both of the following conditions are met:
1. Resident has been classified into a RUG-IV therapy group on a prior assessment during the resident’s current Medicare Part A stay, and
2. No discontinuation of therapy services (planned or unplanned) occurred between Day 1 of COT observation period for the COT that classified them into their current non-therapy RUG-IV group and ARD of the COT that reclassified them into a RUG-IV therapy group.
---- Example: Mr. T classified as a RUA on his 30 day assessment with ARD as Day 30 of his stay. On Day 37, therapy found he did receive the number of therapy minutes to qualify for this RUG, he only received therapy on 4 distinct calendar days, which makes it impossible for him to qualify for RUA and he would not qualify for a therapy RUG group. His rehab regime continued throughout this time period. The facility may complete a COT with an ARD of Day 44 to reclassify him back to RUA.
NOTE: Under these circumstances, completing the COT may be considered optional.

53. COT Observation - Scenario
Mr. C’s 14 day assessment was completed Jan. 3rd Day 1 of the COT observation period began the following day, Jan. 4th and continued for 7 days, Jan. 10th.
When Therapy submitted the minutes on Jan.10th it was found the resident had a decrease in the minutes of therapy resulting in a different RUGS classification. COT Assessment ARD was set for Jan 10th . The observation period began again (Day 1= Jan.11th ) At the end of next 7 day period (Jan.17th ), there was no change, so no COT was needed and the observation period continued.

54. Change of Therapy OMRA – Situation #1
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
1 OT PT
2 OT PT
3 OT PT
ARD
14 Day PPS
4 OT PT
Observ. Period begins
Day 1
5 OT PT
Day 2
6 OT
Day 3
7 OT PT
Day 4
8 OT PT
Day 5
9 OT PT
Day 6
10 OT/PT
Day 7
Check if
COT; Yes, COT ARD
11 OT PT
12 OT PT
13 OT PT
14 OT
15 OT
16 OT
17 OT PT
Check if COT, No
18 OT
19 OT
20 OT
21 OT

55. Change of Therapy (COT)
If Day 7 of COT observation period falls within the ARD window of a scheduled PPS Assessment
SNF may choose
1. to complete scheduled PPS Assessment alone on or prior to Day 7 of COT observation period OR
2. to combine the COT OMRA & scheduled assessment
When combine, COT observation period reset to 7 days following scheduled PPS assessment ARD
If COT done as stand alone assessment or combined with Discharge Assessment must set ARD for a date within ARD window but ARD date must be set no more than two days after the window has passed

56. Combining Assessments
Can not combine:
2 OBRA scheduled assessments
2 PPS scheduled assessments
May combine assessments if ARD meets requirements for assessments
OBRA and PPS
Scheduled PPS and Unscheduled PPS
Unscheduled PPS
Discharge Assessments with OBRA, Scheduled and Unscheduled PPS
If an unscheduled PPS assessment (OMRA, SCSA, SCPA, SWB CCA) is required in the assessment window (including grace days) of scheduled PPS assessment that has not yet been performed, the assessments must be combined. ARD must be set for ARD of unscheduled assessment.

57. Combining Assessment Hint
1. Determine allowable dates for ARD Window of Assessment #1
2. Determine allowable dates for ARD Window of Assessment #2
3. Select an overlapping ARD Window date
4. Always determine effect on RUGS Classification and associated payment prior to combining assessments.

58. 2.13 Factors Impacting SNF Medicare Assessment
Resident expires before or on the 8th day of SNF stay
Resident transfers or discharged before or on the 8th day of SNF stay
Resident is admitted to a hospital
Resident sent to the hospital, not in SNF over midnight, and is not admitted to the hospital
Resident takes a leave of absence
Resident discharged from Part A and returns to SNF on Part A
Delay in requiring and receiving Skilled Services
Non-compliance with the PPS Assessment Schedule
Early or late PPS assessment
Missed PPS assessment
Error on a PPS assessment

59. Additional Medicare Information – Chapter 6
6.3 RUGS IV Summary of Groups
6.4 Assessment & Claim
Short Stay Assessment Guidance
Resident discharged from Part A on or before day 8 of Part A stay and completed only days of therapy, with therapy having started during the last 4 days of the Part A stay
6.6 RUG IV Group
Calculation ADL Scores
Category Classification
6.7 PPS Policies
6.8 Non-compliance with PPS Assessment Schedule

60. Questions?
I’ll take the next few minutes to answer any questions you might have

61. RAI/Education Coordinator
Thank you!!
Please contact me anytime
Shirley L. Boltz, RN
RAI/Education Coordinator